savell's Blog

The concept of autonomy in moral philosophy and bioethics
recognizes the human capacity for self-determination, and
puts forward a principle that the autonomy of persons ought
to be respected. At this level of generality, there is not much
with which to take issue; a full account of autonomy must
further define self-determination and state how and to what
extent autonomy should be respected. Autonomy as a
capacity of persons must be distinguished from autonomy as
a property of actions and decisions, for a person with the
capacity for autonomy may casino act nonautonomously on particular
occasions, for example, a person who is coerced to do
something. Autonomy as a fundamental value and a basic
right is part of the moral and political theory of liberal
individualism. According to this view, autonomous individuals
are the ultimate source of value: The basis for an
action, social practice, or government policy to be right or
good is in the values, preferences, or choices of autonomous
individuals. In social philosophy, individual autonomy as a
basic value and a fundamental right is in tension with
community values, such as caring for others, promoting the
good of society, and preserving and enhancing the moral
practices of society. In clinical bioethics, the right to autonomy
of individual patients is in tension with healthcare
professionals’ obligations to benefit patients. These conflicts
will be examined in what follows.

Advance directives are oral or written statements in which
people declare their treatment preferences in the event that
they lose decision-making capacity. Advance directives may
allow patients to prevent unwanted and burdensome treatments
when struck by terminal illness, permanent unconsciousness,
or profound mental disability. Advance directives
are only one part of a process known as advance care
planning, in which patients, ideally in consultation with
physicians and loved ones, plan in a thoughtful and reflective
manner for medical care in the event of future incapacity.
This entry discusses the various types of advance directives
along with the goals of and the ethical basis for advance
care planning. It explores practical problems associated with
advance care planning and concludes with discussions of
how advance directives are used in clinical practice, and how
decision makers ought to proceed in the absence of a clear
advance directive.
Goals of Advance Care Planning
Advance care planning refers to any planning by patients for
decision making in the event of future decisional incapacity.
Although it could refer simply to signing a form in a lawyer’s
or doctor’s office, ideally it creates an opportunity for
patients to explore their own values, beliefs, and attitudes
regarding quality of life and medical interventions, particularly
as they think about the end of their lives. Patients may
speak with loved ones, physicians, spiritual advisers, and
others during the process. This reflective work can help
patients make important decisions about issues that may
come up even when they still have the capacity to make
ADVANCE DIRECTIVES AND ADVANCE CARE PLANNING
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ENCYCLOPEDIA OF BIOETHICS 3rd Edition 75
decisions. When a patient loses decision-making capacity,
physicians and loved ones who have been involved in the
advance care planning process may feel that they know the
patient’s goals and values better. This allows them to make
medical decisions that are likely to be consistent with the
patient’s values and preferences.
Advance care planning accomplishes a variety of goals
for patients and families. First, patients may use the process
to clarify their own values and to consider how these affect
their feelings about care at the end of life. Second, patients
can learn more about what they can expect as they face the
end of life and about various options for life-sustaining
treatment and palliative care. Third, they can gain a sense of
control over their medical care and their future, obtaining
reassurance that they will die in a manner that is consistent
with their preferences. Finally, patients may increase the
probability that loved ones and healthcare providers will
make decisions in accordance with their values and goals.
Advance care planning may serve other goals, not
directly related to medical treatments. Patients may wish to
relieve loved ones of the burden of decision making and to
protect loved ones from having to watch a drawn-out dying
process. Patients also may use the process to prepare themselves
for death. Advance care planning may help one reflect
more deeply about one’s life—its meaning and its goals.
Patients may reflect on relationships with loved ones, “unfinished
business,” and fears about future disability and loss
of independence. In this way, advance care planning may
improve patients’ feelings of life completion and satisfaction
with their treatment in their final days.